Via the magic of legislative alchemy, chiropractors are already licensed health care providers in all 50 states. Thus their legislative efforts tend to focus on expanding their scope of practice and forcing public and private insurers to cover their services, in some cases at the same rate as medical doctors. Those efforts continue in 2013 with 65 bills impacting chiropractors introduced so far. Of those including substantive provisions (as opposed to, say, simply raising fees), only one is not to their advantage.

New Mexico chiropractors are once again attempting expansion of their scope of practice. In 2008 and 2009, the New Mexico legislature created a new iteration of chiropractor, called “the certified advanced practice chiropractic physician.” A certain faction of the chiropractic industry is attempting to rebrand chiropractors nationwide as primary care physicians and this was a signature event in those efforts. With 90 hours of additional education, these advanced practice chiropractors can administer a bevy of dubious remedies, such as bioidentical hormones.

The new law also permitted prescription of dangerous drugs and controlled substances and administration of drugs by injection, but only if on a formulary approved by the state pharmacy and medical boards. The chiropractic board didn’t like having to get approval from pharmacists and medical doctors, so they went ahead and added what they wanted to the formulary, ignoring the other boards despite their own attorney’s advice that they couldn’t do this. This got them into a couple of court battles with the pharmacy and medical boards. The International Association of Chiropractors (ICA), the traditional, subluxation-only chiropractic faction, jumped into the fray to oppose this power grab. The ICA believes chiropractic should remain drug and surgery free.

To rid themselves of annoying pharmacy and medical board oversight, chiropractors again appealed to the legislature last year and got a bill introduced which would, among other things, let them control their own formulary. That bill passed the New Mexico House but not the Senate.

NM chiropractors go for more

Which brings us to this year. The chiropractors are back with a new bill (Senate Bill 471) and a new attempt to expand chiropractic scope of practice and play at being real doctors. Toward this end, the bill liberally sprinkles the word “medicine” throughout the chiropractic practice act, so that a chiropractor (both advanced practice and the plain vanilla kind) would no longer be engaged in the practice of “chiropractic,” but rather of “chiropractic medicine.” Similarly, existing authority to sell “herbs,” “supplements’” and “homeopathic remedies” is transformed into authority to sell “herbal medicine,” “nutritional medicine,” and “homeopathic medicine.” How very grand!

Not only would chiropractors locate and remove subluxations to restore health and treat disease (so old school!), their scope of practice would now include, but not be limited to,

diagnosis and treatment of a condition for which the chiropractic physician [sic] has been educated and trained.

Exactly who would decide whether a chiropractor has been “educated and trained” sufficiently to diagnose and treat a particular condition is not specified.

The bill appears to do away with the limitation on invasive diagnostic procedures to those permitted by chiropractic board rule. (I say “appears to” because the limitation is deleted in one portion of the bill but remains in another. This bill is no model of careful statutory draftsmanship.) Here’s what the board already authorizes chiropractors to perform (as opposed to order – that’s a different list) to date:

The collection and testing of human fluids, such as saliva, blood, urnine, vaginal and seminal fluids, hair, feces, and conventional radiography.

In other words, no operative surgery or controlled substances unless the chiropractic board says it’s ok.

To get the full import of this provision, it must be read together with the proposed expansion of chiropractic scope of practice to include “treatment of a condition for which the chiropractic physician has been educated and trained.” Under existing law, the chiropractic board attempted to include drugs on the formulary for uses which, according to the medical board, were not within the chiropractic scope of practice. This is what got them into a tussle over the formulary. That scope is currently defined in the traditional manner as “locating and removing interference with the transmissions or expression of nerve forces in the human body by the correction of misalignments or subluxations” and “the administering of all natural agents to assist in the healing act,” e.g., herbs, homeopathic products, and the like.

The “we are primary care physicians” faction of chiropractors thought this cramped their style. So if this bill passes, any chiropractic school can “educate and train” chiropractic students in whatever it pleases – say, psychiatry or gastroenterology – and the scope of practice will be practically unlimited, at least in New Mexico. You can bet the chiropractors will try this trick in other states.

The bill is confusing on operative surgery as its provisions are conflicting. The ICA thinks it “potentially” allows operative surgery so we’ll go with that interpretation. I don’t know if this is yet another example of bad drafting or the drafters are just being sneaky.

Thus, under this bill, the chiropractic board, which consists of four chiropractors and two public members, could decide on its own to allow chiropractors to perform operative surgery, “potentially.” There are no requirements in the bill which the board must follow in determining who is qualified to practice surgery or which surgical procedures can be performed, as long as the chiropractor is “educated and trained” in the subject. Chiropractors are forbidden from “procuring, aiding or abetting a criminal abortion,” the implication being that they can perform legal abortions if so “educated and trained.”

Under current law, an “advanced practice” chiropractor must complete 90 clinical and classroom hours and pass a test in addition to the usual requirements for a chiropractic license. The chiropractic board is given sole authority to develop a formulary for the prescription, administration (including by injection) and dispensing of certain substances such as herbal and homeopathic “medicines,” vitamins and minerals, glandular products, live cells products, enzymes, amino acids, lidocaine and procaine for the “advanced practice” chiropractor. To this list the bill adds carbohydrates and sugars. Any substances not listed in the bill can be added to the formulary by the chiropractic board if the pharmacy board approves. Gone is the requirement for medical board approval.

To prescribe, administer or dispense legend (prescription) drugs or Schedule III through V controlled substances, an advanced practice chiropractor must, in addition, hold a prescription certificate. This requires completion of a “primary care clinical rotation” at a chiropractic college or other accredited “institution of higher education or professional school.” The rotation consists of 500 hours of “clinical and hands-on instruction” in clinical pharmacology, evidence-based clinical assessment, clinical pharmacotherapeutics, primary care case management or (not “and” but “or”) patient safety and standards of primary care under the supervision of an M.D., D.O., nurse practitioner or advanced practice chiropractor. No exam is required.

So, let’s see. After what would equal a little more than 6 weeks of a medical residency, all of which could take place in a chiropractic college outpatient clinic, an advanced practice chiropractor could prescribe, administer and dispense Schedule III – V drugs if the chiropractic board wants them on the formulary and the pharmacy board agrees.

You can see where this is going. Together with the expansion of the scope of practice, this certificate will be a ticket for the advanced practice chiropractor to do pretty much anything a real primary care M.D. or D.O. can do.

So far, the only sponsor of this bill is Senator Cisco McSorley (D). Perhaps some of you might want to drop Sen. McSorley a line with your thoughts on his bill.

Before we move on to other areas, one other practice expansion effort is underway, this time in Texas. Currently, the chiropractic scope of practice includes

objective or subjective means to analyze, examine, or evaluate the biomechanical condition of the spine and musculoskeletal system of the human body

House Bill 1169 would add to the end of that sentence

. . . or the condition of another system of the human body that is affected by the musculoskeletal system.

Which leads me to wonder: considering the vertebrae-centered chiropractic belief system, what wouldn’t be “another system of the human body that is affected by the musculoskeletal system?”

Informed consent, finally?

In Oklahoma, Senate Bill 451 provides

Chiropractic physicians in this state shall obtain informed, written consent from a patient prior to performing any procedure that involves treatment of the patient’s cervical spine and such informed consent shall include the risks and possible side effects of such treatment including the risk of chiropractic stroke.

Physicians and properly trained, experienced PAs and NPs are qualified to do these exams. Chiropractors and other alternative providers are not, even with special certification and training.

As noted in my recent post on naturopathy, chiropractors are seeking to avoid exclusion, which they equate with discrimination, from Oregon’s Coordinated Care Organizations (CCOs) through a bill that would force CCOs to accept them as primary care providers. The CCOs, which provide care for Medicaid patients, were merely trying to follow a legal mandate to save money by requiring providers to practice evidence-based medicine and excluding those who don’t. Never underestimate the power of a state legislature to take away with the right hand taxpayer money the left hand is trying to save.

Insurance

The majority of chiropractic bills introduced so far seek greater public and private health coverage for chiropractic services. Pending bills would, among other things,

include or expand coverage of chiropractic services in Medicaid or other taxpayer-funded health insurance programs;

prohibit coverage limitations on chiropractic services unless there are similar limitations on physician services or require coverage of services on same basis as a physician;

require coverage for any service within the scope of chiropractic practice;

prohibit larger copayments for chiropractors than for physicians.

There is considerable financial pressure on chiropractors and thus an urgent need to increase income, even if it means singing up for low reimbursement programs like Medicaid. The total number of ambulatory visits to chiropractors decreased by 3 percent from 2002-2008. Quackwatch recently analyzed chiropractic income based on data from the U.S. Department of Commerce:

These figures indicate that between January 1992 and December 2007, the average gross income per chiropractic office rose at less than half the rate of inflation, which is equivalent to a loss of 20% in purchasing power. Since the cost of running the offices increased during this period, the purchasing power of the chiropractor’s take-home pay was even lower.

And just this week Scripps-Howard News Service published a news report revealing the large number of defaults still outstanding on government health care provider student loans. A complete list of the 930 providers (see bottom of report) reveals that chiropractors hold a distinct majority on the list.

Conclusion

Instead of ditching the subluxation and becoming an evidence-based provider of care for musculoskeletal problems, chiropractors appear to being going in the extreme opposite direction. They are attempting to become primary care physicians but with far less education and training than M.D.s, D.O.s, P.A.s and nurse practitioners have in diagnosing and treating the broad range of conditions seen by primary care providers. They compound the problem by using quack remedies like homeopathy. If they can fool some of the public some of the time with this nonsense, I don’t think it will be for long. As is true of “naturopathic doctors,” very few patients will see chiropractors for primary care even when their scope of practice permits it and insurance pays for it. And it will just compound the problem the public has figuring out just what it is chiropractors do.

27 thoughts on “Legislative Alchemy: Chiropractic 2013”

Jann, I don’t understand how a chiro can be a PCP. Are they trained in performing PAPs, doing a cardiac exam, prescribing drugs, etc? I always thought their training focused on musculoskeletal complaints. I once had a chiro explain to me that “Chiros are naturopaths who can’t perform PAPs”

Jann writes: “Together with the expansion of the scope of practice, this certificate will be a ticket for the advanced practice chiropractor to do pretty much anything a real primary care M.D. or D.O. can do.”

May I respectfully suggest that the sentence should read like this: “Together with the expansion of the scope of practice, this certificate will be a ticket for the advanced practice chiropractor to PRETEND TO do pretty much anything a real primary care M.D. or D.O. can do.”

Tanha writes: “Jann, I don’t understand how a chiro can be a PCP. Are they trained in performing PAPs, doing a cardiac exam, prescribing drugs, etc? I always thought their training focused on musculoskeletal complaints.”

Addressing the first part of the above (chiros as PCPs), this is a point that has concerned me for decades – ever since I first learned of their attempt to pass themselves off as point-of-entry healthcare professionals. But first I suggest that the main reason they aren’t even doctors at all is that the basis of what they’re taught and what they practice (even “mixers”) is predicated on the theory that the earth is flat – better know in chiropractic circles as subluxation! Their training, despite what Tanha believes (and what drives most customers to seek chiropractic care) is not “focused on musculoskeletal complaints. The focus is on the “health” of the spine as the key to “wellness” and the correction of spinal subluxations as the road thereto. My years of investigation have led me to the conclusion (perhaps right, perhaps wrong) that the reason chiropractic expanded (maybe “deviated” is a better word) from its original practice of treating all “dis-ease” (D.D. Palmer’s hyphenation) by treating those nonexistent subluxations is that “doctors” of chiropractic slowly became aware of a simple fact: their customers weren’t getting well. They also discovered that some of those customers were getting some relief from backaches and, little by little, the emphasis, as well as public perception, shifted to chiropractors as the go-to guys, or girls, for muscle aches and pains. If my hypothesis is correct this is what led to the proliferation of chiropractic. Without the relief from simple aches and pains, chiropractic would have quietly slipped into oblivion – a fitting demise. BUT!!! This wasn’t enough for chiropractors. They had to cling to their jobs and they gradually added various other, largely naturopathic, modalities to their armamentarium, thus the rise of “mixer” chiropractic which now constitutes roughly 75% of the practice.

That said, I’ll finally get to the first part of Tanha’s concern: the DC as PCP. Tanha is 100% on the mark! Chiropractors don’t have either the training or experience to act as primary care, point-of-entry practitioners. 90 hours of training indeed! There are residents who work a 90 hour WEEK! Even if they’re authorized by state boards (or whatever) to order blood tests, ekgs, etc. – what exactly would DCs do with the results – even assuming they have the slightest clue as to what they mean? To keep this overlong response from getting more out of hand, I’ll cite one specific case: my own. I suffer from atrial fibrillation. Is there a “doctor” of chiropractic who can honestly claim that he could diagnose and/or treat this condition? I’m not a gambling man but, if I were, I’d say the odds are mighty slim that such a DC exists (other than the rare breed who also holds a legitimate medical degree).

I have had the dubious privilege of hearing both a naturopath and a chiropractor utter the words (nearly identical in both cases), “I’m a doctor too, just a different kind of doctor”. I guess it’s all in your interpretation of “different”.

Which reminds me: Can anyone tell me what a podiatrist is? Is he/she more along the lines of a physical therapist or optometrist or more like a chiropractor/naturopath? Someone once told me her neighbor was “a doctor” and later she said the woman was a podiatrist. I would google it, but am afraid of what kind of hornet’s nest of confusion I might encounter.

Janet — my podiatrist is an MD. Sort of like an orthopedist who specializes in the foot and lower leg. He performed surgery to repair the joint capsule that I screwed up and which was causing me to limp. Thanks to him, I can run again.

@rwk:
“tgobbi
A-fib with it’s non discernible P waves and irregular R-R intervals is easy to recognize on an ECG. It is taught in
Chiro schools. C’mon man.”

Interesting. Why are you taught to read ECGs in chiro school? How are ECGs used in chiro practice?

“Jann,
What opposition did the osteopathic profession face as they moved over the years from being essentially chiropractors to medical doctors?”

I think you asked me this before. The answer is I don’t know.

@Janet:

“Which reminds me: Can anyone tell me what a podiatrist is?”

I don’t know about Calli Arcale’s podiatrist, but my understanding is they have “Doctor of Podiatric Medicine” degrees, not an M.D. degree, and their scope of practice is more limited than an M.D. Here’s further information: http://en.wikipedia.org/wiki/Podiatry

Jann would know this better than me, but it appears that yes, if its in their scope of practice, under the Harkin provision in the ACA, insurance companies would be required to pay for them.

Mandatory Coverage under the Patient Protection and Affordable Care Act:
42 USC 300gg-5(a) Providers.—A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that providerʼs license or certification under applicable State law. . . .

I think a very general answer would be this — if a chiropractor is treating a disease or condition within his scope of practice and the diagnostic procedure is a legitimate one for use in connection with diagnosing or treating that disease or condition in the circumstances presented and is covered by the policy, then yes the insurance company would pay for it. This is not an area I know much about and one I want to learn. I hope someone more familiar with health insurance will fill us in.

Jann says
Interesting. Why are you taught to read ECGs in chiro school?
How are ECGs used in chiro practice?
The same as in a medical practice,as a diagnostic tool.

If you fancy yourself a healthcare sleuth/fraud buster, expert on all the quackery associated with chiropractic but have no clue about Osteopathy and its evolutionary battle with
mainstream ( SBM?)medicine, why are you writing articles ?

Even more interesting. Could you tell us more about that? How do you decide a patient needs an ECG? What diagnosis within the chiropractic scope of practice would findings from an ECG be relevant to? Do you read the ECGs yourself?

Sayeth rwk to Jann: “What opposition did the osteopathic profession face as they moved over the years from being essentially chiropractors to medical doctors?”

This one’s a no-brainer. The concept of opposition is irrelevant here because any group is going to try to protect its turf for a while. The point is that the DOs wanted to become legitimate healthcare professionals. As in science-based, mainstream practitioners. DCs, on the other hand, want to continue to fit the square peg of chiropractic into the round hole of proper healthcare. But they can’t give up chiropractic because they insist on being different from proper doctors. Kinda like a “separate but equal” ploy.

Until the inhabitants of “mondo chiropractico” give up vitalism (as in subluxations and “innate”) along with the naturopathic modalities that constitute most of “mixer” practice they’re gonna continue to be regarded as the lunatic fringe.

Today’s podiatrists are specialists, medically and surgically trained to treat the foot and ankle. From sports injuries and diabetes complications to pediatric deformities and heel pain, podiatrists are able to tackle all of your foot care needs.

Licensed in all 50 states, the District of Columbia and Puerto Rico, there are approximately 15,000 podiatrists practicing in the United States. Here are answers to frequently asked questions (FAQs) about today’s podiatrists.

Q. What is the difference between a podiatrist, podiatric physician, and podiatric surgeon?

A. Podiatrists, podiatric physicians, and podiatric surgeons are all terms used to describe doctors of podiatric medicine (DPMs). All are uniquely qualified among medical professionals to treat the foot and ankle based on their education, training, and experience. The amount and type of surgical procedures performed by podiatrists may vary based on each individual’s training and experience and personal choice within their practice.

Q. What type of medical education do DPMs receive?

A. DPMs receive medical education and training comparable to medical doctors or doctors of osteopathic medicine, including four years of undergraduate education, four years of graduate education at one of nine podiatric medical colleges, and two or three years of hospital-based post-graduate residency training.

Q. Are podiatrists restricted to treating the foot and ankle only?

A. Although a podiatrist’s scope of practice can vary from state to state, all states permit treatment of the foot, while 44 states also permit treatment at or above the ankle.

Doctors of Podiatric Medicine (DPMs) are licensed under Section 2472 of the State Medical Practice Act. They diagnose and treat medical conditions affecting the foot, ankle and related structures (including the tendons that insert into the foot and the nonsurgical treatment of the muscles and tendons of the leg). Any procedure and modality is within the DPM scope if utilized to diagnose and treat foot, ankle or other podiatric conditions.

In addition to performing foot and ankle surgeries, DPMs are also licensed to assist medical and osteopathic doctors (MDs, DOs) in any surgery–podiatric or non-podiatric.

DPMs are trained and fully licensed to independently perform full-body history and physical (H&P) examinations in any setting for any patient.

DPMs, many of whom develop expertise in the care and preservation of the diabetic foot, perform partial amputations of the foot as far as proximal with the Chopart’s joint, to prevent greater loss of limb, ambulation, or life. They order and administer anesthesia and sedatives, as indicated. The administration of general anesthesia, of course, may only be performed by an anesthesiologist or certified registered nurse anesthetist (CRNA). DPMs commonly administer intravenous (IV) sedation.

A small number of DPMs licensed prior to 1984 have not met the Board of Podiatric Medicine’s (BPM’s) licensure requirements for ankle surgery, amputation, and surgical assistance to MDs. They may assist other DPM surgeons in any podiatric procedure and may assist MDs as non-licensed operating room technicians do in non-podiatric procedures. Facilities may verify license status online [www.bpm.ca.gov/] by clicking on the Quick Hit for license verification. This will be indicated by “License or Registration Class: ANK”, and authorizes the full DPM medical scope.

Section 2472 also specifies the various peer-reviewed facilities in which ankle surgery may be performed. It may be viewed in its entirety from BPM’s website under Laws & Regulations. BPM interprets surgical treatment of the ankle to include those parts of the tibia, fibula, their malleoli and related structures as indicated by the procedures.

Hmmn. Why would a person elect to become a podiatrist, rather than an MD?

Just to make your day I found this:http://www.mobilitywod.com/2013/01/triceps-smash.html#comments
“””
Love that you make a connection between the hamstrings and the triceps. I’m an acupuncturist and when treating musculoskeletal disorders and pain I use this same type of imaging (I like “analog”). For example, if someone comes in with hamstring problems, I put some needles in the opposite triceps and have the patient test it out by walking, stretching, whatever would normally illicit the pain. The pain decreases or disappears completely. Awesome stuff.
“””

Thank you for staying on top of these developments. It is very important that skeptics be aware of these legislative actions when they come up.

But at the same time, where is your call to action? Clearly, skeptics and other readers in Oklahoma and New Mexico should be contacting their legislators about these developments. It makes no sense for skeptics to decry these developments and then fail to work against them. But we need articles like this to point this out, and point us in the right direction for action.

Jann and other skeptical bloggers I plead with you – when you write an article like this about pending legislation, please research and include the correct contact points for skeptics to complain. And admonish your readers who live in that jurisdiction to do so. It is our civic duty, we need to do it.

Regarding the question of why someone becomes a podiatrist, I have an…*ahem*…ANECDOTE: A friend was in medical school several years ago, and I mentioned that an acquaintance was a podiatrist. He chuckled and said something to the effect that podiatry was for people who couldn’t quite hack it at med school; I gathered that it was sort of the “trash bin” of the MD profession. To what extent it’s really the ugly cousin of “real” specialties or whether that was just type-A med-schooler snark, I dunno. I suspect that treating feet just isn’t that romantic in comparison to something like orthopaedics or plastics.

I was at the dentist today, and they had a recent experience with a chiropractor. Apparently one of their elderly patients was told by her chiropractor to have all of her dental fillings removed. The dentist’s office explained it is very invasive, can damage the teeth and the removal releases more mercury from the amalgam. They talked her out of paying them lots of money to damage her health.

It’s way late to be replying, but I was prodded to finally look up podiatry for myself. It seems to be an orthopedic specialty and one cannot help asking why these individuals do not simply go to regular medical school and specialize in orthopedics? And why on earth would Calli Arcale’s MD also have a DPM unless (s)he finally got into medical school?

I’m sticking with the orthopedist although I shall henceforth hold DPM’s in much higher esteem than chiropractors and more on a level with the optometrist.